Provider Demographics
NPI:1104603604
Name:INGERSON, JILLIAN MARY BEAL (LMT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARY BEAL
Last Name:INGERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:MARY
Other - Last Name:BEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:ME
Mailing Address - Zip Code:04489-0006
Mailing Address - Country:US
Mailing Address - Phone:207-992-4000
Mailing Address - Fax:207-558-3285
Practice Address - Street 1:130 PERRY RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6722
Practice Address - Country:US
Practice Address - Phone:207-992-4000
Practice Address - Fax:207-558-3285
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4637225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist